If all the known world is a number, do you know your healthcare world; specifically your patient and operation numbers and how they correlate? Do you know the numbers of other healthcare organizations in comparison to your numbers?

As I write this post the Worldometers.info has reached almost 7.7 billion people. Every one of those people needs healthcare. It blows my mind. What is the healthcare data on 7.7 billion people?

According to Our World in Data, Americans have a life expectancy of 79.2 years. They estimate that the last 11.6 of those 79.2 years are spent living with disability and disease. With the new value-based payment structure and the population aging, how will healthcare organizations manage these populations and keep healthcare organizations fiscally sound?

While we may never know the healthcare data of 7.7 billion people, a healthcare organization could and should know their healthcare world numbers by creating and monitoring its patient and operations data and correlating it to know with 98% accuracy it's demand and capacity at any given time. These collected numbers are called data analytics and are used to manage the world from which the numbers were collected. There are three type of data analytics:

Descriptive Analytics: Uses data aggregation and data mining to provide hind sight into the past to answer the question, “What has happened?”

Predictive Analytics: Uses statistical models and forecast techniques to provide foresight into the future to answer the question, “What could happen?”

Prescriptive Analytics: Uses optimization and simulation algorithms to provide insight into the present and answer the question, “What should we do?”

The Infinitum Healthcare Transformation System looks at a healthcare organization's numbers and applies data analytics to understand what has happened in the past, what could happen in the future, and what is the best practice for the present based on the patient and operations data. Would you like to know the numbers of your healthcare world? Contact Infinitum to learn more.

References

Our World in Data. 14 March 2019. Website address: https://ourworldindata.org/#entries

Pythagoras, Greek mathematician and philosopher. 11 March 2019. Website address: https://www.google.com Searched: All Known Things have Number

In healthcare organizations, the data goes with the flow of the patient. Every step a patient takes creates a data footprint. Data literally follows the patient through the patient pathway within the healthcare organization like bread crumbs in the forest. When data is collected over a length of time, predictive data exists that can actually predict where the bread crumbs will fall with 98% accuracy within a given day, month, and season!

The first question is: are you collecting this data? It is important to collect this data in order to optimize patient flow throughout the healthcare organization as it is essential to ensuring safe, high-quality, patient-centered care.

The second question is: do you know what to do with the data? When this data is applied, for example, to a current state value stream map clinicians can see where waste exists by assessing the problem areas and identifying major areas of opportunity for change. Or maybe you'd like to balance demand and capacity through load leveling?

The Infinitum Healthcare Transformation System is based on the lean Toyota Production System that provides the right care at the right place and at the right time. Waste is removed from the patient pathway by the people doing the work as lean methodologies are learned such as visual management. Employees learn to work as a collaborative team and individual QI experts resulting in innovative problem-solving. When data is collected, monitored, and analyzed through the lens of system thinking the healthcare organization can ensure that capacity can meet the demands for services, prevent overcrowding, create predictable scheduling, and calculate the return on investment.

Last question: would you like to go with the flow of your patient data? Contact Infinitum! We will customize a learning package that fits your healthcare organization size and implement actionable strategies, transferable knowledge, and ensure a data-driven work culture.

It's true, you really don't know what you don't know until you become aware of it. This is more than an amusing adage as it speaks to the need for information. Information that reveals factual data to create awareness. According to Google, awareness is the "knowledge or perception of a situation or fact." Ever wonder if something is really true? Your mind tells you one thing and your gut tells you another. Somehow the human heart negotiates between the two to make a decision. But how do you know if it's the right decision until you have all the information?

When data is collected and analyzed, it reveals truth and provides knowledge. What is something you'd like know? How about the demand and capacity of your healthcare organization? Would you like to know how many people in the population you serve need to be seen and how often? Would you like to know if these patients are being scheduled correctly? Would you like to know if your demand and capacity line up? Even if your gut had a crystal ball you would never be able to guess that information. What do you need? Data! And lots of it. Preferably a year's worth, and it can be pulled from your EMR. A year's worth of data to show the fluctuations from day to day, month to month, and season to season. For example, in the fall you know you're going to have a lot of flu vaccine appointments and sport physicals before school starts. Or maybe your data will show that Mondays are consistently over scheduled.

Now that you have the data, what are you going to do with it? Here are some basic steps:

Sort the patient data by provider and appointment to create upper and lower control limits. You quite literally can see the demand over time; days, weeks, months, and seasons. (There is so much you can do with this information including the takt time of the practice. We will discuss this more later, but for now, let's stay focused on demand and capacity.)

Pull your EMR procedure list and sort them by time to create service families.

Perform a patient time study on procedure time.

Compare the appointment times against the actual visit time.

Perform a root cause analysis to determine why the appointment times and actual visit time do not match.

Create a countermeasure plan to address the service family deltas.

Complete another patient time study to confirm that procedures are now correctly organized within the service family.

Analyze how many clinical hours and compare against demand.

Perform a root cause analysis to determine why the schedule does not accommodate the population.

Create a countermeasure plan to address the demand and capacity deltas to adjust the work load and alleviate burnout.

We've all heard the term "data-driven decision making." Why has this become so popular in system thinking? Because without data you do not have the information you need to become aware of the situation and make the most informed decision. Data will back up any decision reliably. The numbers don't lie, but your gut can. Would you like to know what you don't know using data? Contact Infinitum, the healthcare transformation system that relies on data!

Have you heard yourself tell other people those three little words? If you haven't, have you taken the time to ask yourself why? Obviously, you're passionate about your patients, the work that you do, and the people you affect or you wouldn't be where you are. Right? So what are the items that fall under the "con" column in your work life?

Lack of joy at work affects everyone in healthcare, but let's look at what a physician might have in their "con" column. According to Medscape's National Physicians Burnout, Depression & Suicide 2019 Report, 44% of the physicians surveyed in October 2018 reported that they felt burned out. And what were the top three biggest contributors? Too many bureaucratic tasks, spending too many hours at work, and "increasing computerization of practice." According to the Advisory Board's 2019 survey report, 21% of a physician's work hours are spent on non-clinical paperwork, and 54% stated they were emotionally exhausted. Sadly, this data confirms what you already know: we have a national crisis in American healthcare.

So, how is this crisis being addressed? Physicians were also asked how they cope with burnout and the top three answers were: exercise, talk with family members and close friends, and "isolate myself from others." Can you see how the root cause of the problem is not being addressed and the coping tactics are just a bandage for the real problems? There are people working together across the healthcare industry to try and find a solution for the future, but what about right now?

Infinitum can offer you a "right now" solution: assessment, transference of lean knowledge, root cause analysis, countermeasure projects, and implementation. The Infinitum Healthcare Transformation System begins with an assessment by an Infinitum Consultant, a lean healthcare expert, who will evaluate the healthcare organization for:

Current improvement methodology.

Strategic alignment of the board of directors, executives, management and frontline staff with respect to the organization's goals.

Alignment of overall priorities in the adoption of a lean management system.

Behaviors and policies that demonstrate implicit or explicit principles and expectations of leaders and staff that can accelerate or impede the adoption of a lean healthcare management system.

The consistency of the day-to-day approach of implementing process improvements that will provide sustainable growth and benefits to future growth strategies.

Enable a multidisciplinary group of stakeholders as participants to envision, simulate and co-create a future-state vision for implementation.

After the assessment, the Infinitum Consultant will customize a learning and training package for the healthcare organization based on the desired level of implementation. Infinitum offers lean healthcare methodology through the Infinitum University online education modules; on-site or virtual workshops, training, and certification for your quality improvement people or the organization as a whole; and consultant support at every level of the chosen learning and training package. Infinitum consultants are experienced multidisciplinary transformation experts who will assist a healthcare organization to design and promote a consistent day-to-day approach to implementing process improvement across the healthcare organization; achieving a sustainable culture of change and collaboration, and operations fine-tuned to deliver value to your patients while improving work relationships and reducing the mental load.

At Infinitum we help people address their "con" column by addressing the root causes within a given healthcare organization. Would you like to hear yourself say, "Love my work?!" What are you doing "right now" to improve your joy at work? Contact Infinitum!

Organizations love lean because it works when properly implemented. This implementation requires that the whole team be willing to look at healthcare through the lens of data and become reliant on data-driven decisions. Yes, this process improvement methodology came from car manufacturing, however, it is transferable when it comes to reducing inefficiencies and improving patient value with their healthcare being the end product. Lean has three key goals:

Eliminate waste

Value employees

Continually improve

What is interesting about the three goals is that they work synergistically. You cannot meet one goal without meeting the other goals. Through the inclusive process of eliminating waste by focusing on non-value added activity; keeping inventory low by only storing what is needed when it is needed; embracing technology to provide data and reduce manual labor, valuing employees by developing people, and continuously improving by focusing on the root causes the synergy happens. Healthcare organizations across the country are learning to love lean as their awareness of the transformation in the way they look at the patient flow via data grows.

Recently the Infinitum Transformation Team was conducting a Value Stream Map Workshop, also known as the Transformation Acceleration Program or TAP Workshop. At the table was a representative from each work area discussing delay area 2 on their current state value stream map. One of the delays was that the "providers were running late." Through the 5-why root cause analysis it came down to the providers being late because the previous appointment took longer than expected. This happens, but upon further investigation, it was discovered that this happens frequently as in more than 50% of the time. The Infinitum Transformation Team walked them through the data mining process of figuring out their demand and capacity so that they are now scheduling patients within the appropriate time slots by creating service families; processes were reconfigured to meet the time limitations; and they learned how to create a demand chart from their data showing upper and lower control limits to address the patient demand variations with 98% accuracy.

Lean on lean; it's reliable! Contact us to learn how your organization can transform for the love of lean.

The heart of lean healthcare is to create value by eliminating waste. It's hard to imagine that there is any waste when all efforts are for the patient. After all, where would the human race be without medicine and the professionals that care for us? So let's define waste within the framework of patient flow. Waste is the non-value added activities or the inefficiencies within a given process or workflow of a system; in this case, healthcare. Gain or value-added services are what the patient is willing to pay for. Every step in a process is either value added or it non-value added. Non-value added activities fall within these eight categories:

Unused Talent or Creativity: Sharing of knowledge and ideas, working to the top of a license or skill level, and a safe culture that respects creativity.

Waiting or Reoccurring Delays: Waiting to be roomed, waiting to see the provider, or waiting for an x-ray are a few examples.

According to Maureen Bisognano, President Emerita of the Institute for Healthcare Improvement and a Senior Fellow, the top reason to improve patient flow is to reduce patient that feels disrespectful to patients and families. This stress on the patient is also stressful on the clinicians and staff because it negatively affects them and creates burn out. Lean provides a way to create a more effectively designed and managed process that supports clinicians and staff morale resulting in increased joy at work, reduced stress, and increased productivity and job satisfaction.

There are opportunities to remove non-value added activities within the interconnected processes in any and all healthcare systems. Lean is a multi-faceted methodology that requires a simultaneous application within a healthcare organization in the micro, meso, and macro work levels. The Infinitum Healthcare Transformation System is designed to work with and integrate all three levels:

Some lessons from the field have taught the Infinitum Transformation Team:

It starts with leadership. Employees look to leadership for permission to be innovative, autonomous, and collaborative within a team.

Purpose (sets the direction), Process (how people do it), and People (organizational values that drive action). A shared vision is a co-created story that everyone plays a part in. Sustainable change happens when everyone moves in the same direction while aligning their actions to a shared vision.

The vital few must be identified. A system-wide transformation requires representation from each work area. It was Italian economist Vilfredo Pareto that reported in 1906 that 80% of the land was held by 20% of the people. He also noticed that 20% of the pea pods in his garden produced 80% of the peas. This principle of factor sparsity or the law of the vital few is known as the Pareto Principle. This statistical distribution of data states that 80% of a specific event can be explained by 20% of the total observation, or 20 percent of an activity will account for 80 percent of the results. Therefore, the 80-20 rule is a very helpful concept for life, time management, and work. A modern day example, Microsoft observed that 80% of the operating system crashes were eliminated by fixing 20% of the most reported bugs.

Identify issues through learning rather than blame. Learning is a curiosity rather than an assumption. The Infinitum Transformation Team asks "why" rather than "who."

Customer satisfaction through patient flow is the patient's perspective on how they move through a healthcare system.

Methods matter as much as results.

Back to the data; always back to the data. Not only the average, minimum, and maximum, but how often and within what control limits?

Healthcare organizations are businesses providing a service, and like all businesses, they need to focus on achieving a positive ROI (return on investment) to stay in business. The lean process can give you between 20%-60% cost savings and more work capacity which equals more profit. Lean methodology provides evidence that quality improvements are sustainable in the long term and are culture changing. The Infinitum Healthcare Transformation Team can help you get at the heart of the matter!

The Infinitum Transformation Team is passionate about their work. They have witnessed firsthand how lean methodologies such as value stream mapping works to increase capacity at healthcare organizations. In addition to removing waste, creating efficient processes, boosting staff morale, and addressing provider burnout, lean methodology also helps people to see how their work in interconnected to the work of others within the system of care. This self-awareness is a catalyst for change not only in the work they do, but in the relationships between the team members.

Within the Infinitum Healthcare Transformation System we have a value stream mapping workshop that we call TAP (Transformation Acceleration Program). The TAP workshop is one of many lean methodologies used by the Infinitum Transformation Team. The Infinitum Transformation Team has observed that the TAP Workshop has an effect on relationships in many ways:

TAP looks at processes and not people. TAP is a non-judgmental workshop that creates a safe space for people to think about how their work fits into the value stream without feeling judged. (Depending on the number of people the workshop can usually be done in 4 hours with additional pre-work and post-work hours with one designated contact.)

TAP creates a shared view of the patient pathway which puts the team members on the same mission to find waste and improve the patient experience by problem solving together.

TAP instills a shared knowledge of a quality improvement lean technique that the team members can continue to use long after the Transformation Team is gone.

In addition to the improved team member relationships and employee satisfaction, the patient relationships are improved also as they will move more efficiently through the practice system of care by having better scheduling management and less waiting.

Recently the Infinitum Transformation Team was contracted to deliver a TAP Workshop to a primary care practice. There was tension between two of the providers because one provider consistently saw more patients each day. The cause was that the other provider talked longer with each of her patients. The provider seeing more patients considered this a problem because the other provider wasn't staying within the allotted appointment time which then cascaded through the patient pathway making each consecutive patient wait longer for their appointment. The provider seeing less patients believed that taking more time with the patient meant giving them more care. They wondered how to fix the problem, and didn't know how to avoid a conflict. Does any of this sound familiar?

It was a beautiful thing to witness the two providers become aware of each other's view, and the provider who saw less patients shared how she now saw how she was holding up the patient flow in the name of care. This new shared awareness created the non-judgmental space to talk about the situation and brainstorm about how to keep the system moving on time and provide the best possible care. This is part of the IDEAL state we teach in the TAP Workshop.

We spend more time with the people we work with than our family and friends. Work relationships matter that much. We all want healthy relationships where we are respected and can work collaboratively within a non-judgmental or safe space. The TAP Workshop provides the awareness and process to support that goal. Additionally, the patient relationship has as much importance. They trust the people within a healthcare organization to provide them with the care they need. A healthcare system is complex because of the different relationships interconnected processes. Every person within that system touches the patient from the front desk that makes the appointment to the checkout desk that might schedule a test or a follow up appointment.

The Infinitum Transformation Team, like the healthcare industry we serve, are passionate about our work because we see how lean methodologies like the TAP Workshop affect relationships and the processes within a healthcare system. It is from the heart of our experience that the Infinitum Transformation Team wants to support your relationship goals and quality improvement programs. Contact us and tell us about the relationships that matter to you.

Dr. W. Edwards Deming is one of the Infinitum Transformation Team's favorite lean leaders. He was a business consultant, statistician, engineer, author, and professor. As a leading management thinker in the field of quality, he played a major role in the post-war WWII recovery in Japan and worked closely with leaders of Japanese industry. Dr. Deming is credited for launching the Total Quality Management movement.

In his book "Out of Crisis" Dr. Deming writes about his "System of Profound Knowledge" which contained four points of views: appreciating a system, understanding variation, psychology, and the theory of profound knowledge. The theory of profound knowledge is a management philosophy grounded in systems theory. It is based on the principle that each organization is composed of interrelated people and processes that are the components of a system. His 14 point Total Quality Management Principles are:

With the aim to be competitive and to stay in business, create jobs and consistency of purpose toward improvement of product and/or service.

Adopt the new management philosophy because the times have changed and America needs to wake up to the challenge, learn their responsibilities, and take on leadership for change.

Stop dependence on inspection to achieve quality. Eliminate the need for inspection and build quality into the product/service.

Cease the practice of awarding business on the basis of the purchase price of a product/service, and instead minimize total cost. Business relationships are long-term and are built on loyalty and trust.

Constantly improve the system of production and service and drive down cost.

Institute training on the job is a must.

Leadership should aim to help people and machines and gadgets to do a better job.

So that everyone may work effectively for the company, drive out fear.

Break down barriers between departments to create cross-functional teams to foresee problems of production/service.

Eliminate slogans and targets for the work force asking for zero defects and new levels of productivity as they create adversarial relationships because the main cause of low quality and low productivity belong to the system and beyond the control of the workforce.

Remove barriers that rob hourly people of their right to have pride in their work. It is the responsibility of leaders to provide focus on quality first.

Remove barriers that rob salaried people of their right to have pride in their work. This means the termination of annual or merit rating and of management by objective.

Institute a robust education and self-improvement program.

Everyone should be working on accomplishing transformation as it is everybody’s job.

In addition to the above philosophy and management principles, Deming is the creator of the Deming Cycle, also known as a PDCA (Plan-Do-Check-Act) or PDSA (Plan-Do-Study-Act). This lean methodology is a continuous quality improvement tool consisting of four repetitive steps in a logical sequence for continuous improvement and learning. This lean tool is best used for small rather than complex problems.

Dr. Deming was certainly a leader in the quality management field. He led by example over a lifetime of teaching others that there is a better way to lead. We believe that part of his success was that he understood people and how they worked. We recommend watching the Red Bead Experiment. The Infinitum Transformation Team understands people and how they connect to the complexities of a healthcare system and their required involvement in quality.

Heroes are not born, they are developed by collective leaders. But what exactly is a collective leader? Sebastian Salicru, business psychologist, leadership development expert, executive coach, facilitator, researcher and author for The Professional Training Services (PTS) defines collective leadership as:

"Collective leadership is a social process aimed at accomplishing collective rather than individual goals and it requires collective and coordinated action. Terms such as 'collective', 'shared', 'distributive' or 'emergent' leadership are often used to describe very similar concepts."

Collective leadership sounds a lot like lean leadership. Like lean leadership, collective leadership breaks down silos; increases knowledge sharing across organizations; power structures change direction; team identification with team responsibility and accountability; greater utilization of talent, higher levels of engagement and commitment; improved inclusion and acceptance of multiple voices; rapid acceptance of change and implementation of innovation; and greater coordination of action and performance outcomes which all lead to better business results. The difference between the two is that lean leadership originated from the business world while collective leadership originated from the social world.

Cassandra O'Neill and Monica Brinkerhoff of The Nonprofit Quarterly (NPQ) wrote that collective leadership looks at an organization as part of a system instead of a machine. While Western leadership functions from hierarchy, the lean and collective leadership functions as a connected network. Decision making is shared as there is an assumption that people are inherently capable and can be trusted to do the right thing. The focus moves from the individual super hero to the team of super heroes and the belief that success comes from the diverse perspectives and skills of the many. Furthermore, collective leaders empower people to work with multi-steak-holders by collaborating with cross-sectors within community initiatives that have a shared vision. These transformed heroes on the ground, according to the NPQ article, benefit from collective leadership by:

Increased self-direction and internal motivation is the best way to eliminate resistance to change.

Removing barriers to internal motivation is needed for growth and development through forming a partnership toward a shared goal.

Shared responsibility makes the workload lighter and feels more successful.

Realizing potential is important for people as it leads to job satisfaction and better job performance.

Increased engagement and investment happens when leadership is shared and it energizes people to create.

Sustainability is maintained in the knowledge of the many, and change is supported by the knowledge.

Whether within the organization's system or without as part of a larger system of organizations, according to Reem Rahman, et all, of the Social Innovation Journal, collective approaches to system changes can be seen as having five major motivations:

"an effective way to tackle the nature of complex social problems. Certain social problems have the qualities of being large-scale, multi-sector, interconnected, and constantly changing, so they require solutions that have those same qualities as well;

designed to remain accountable to having impact that reaches the entire community served;

a more efficient way to optimize resources to overcome fragmented, "service delivery chaos11" by leveraging resources outside of just a single organization;

an essential way to keep up with the hyper-pace of innovation and change and ensure sustainable value chains; and

a more realistic way to ensure sustained impact because they pay deliberate attention to diversifying the stakeholders as co-owners."

Rahman and his co-authors of the Social Innovation Journal further believe there needs to be two major mindset shifts in order for collective leadership to be fully accepted:

Top-down or hierarchical leadership is no longer effective; and acceptance that a few people making key decisions is now spread to many different people and organizations to lead a collective approach to leadership is a better way.

The methodology of change from strategic planning to emergence. By tackling the root cause of problems through the knowledge that many factors affect every problem within a system. This wider thinking for problem solving looks at the problem as a symptom that is created by interactions within many system loops. Beyond strategic plans is asking the right questions, listening for what matters, and involving all that are involved so that the direction to move emerges from the chaos.

Imagine what would happen if collective and lean leaders were ubiquitous? What if every organization embraced collective and lean leadership? What would it be like if people from all areas of an organization functioned collectively with the organizations they interact with? What would it look like if we empowered all people to be collective heroes? If the healthcare system were to change over to a collective and lean leadership style, how many heroes would be made? This is, after all, the next evolution in healthcare: create the greatest value possible for the patient while connecting the community resources to the patient for the best health outcome.

Let Infinitum show you how to make heroes in your organization. Contact us to find out how!

'Go to the people. Live with them. Learn from them. Start with what they know. Build with what they have. But with the best leaders, when the work is done, the task accomplished, the people will say "We have done this ourselves." ' —Lao-Tsu, founder of Daoism

There are leaders and then there are lean leaders. What's the difference and why are they better?

Lean leaders create a culture where change is embraced as an opportunity for improvement and innovation. People are natural problem-solvers and the lean leader increases this skill with lean management. Lean leaders use their authority to manage people in the following methods:

Create a shared vision: By creating a shared vision the lean leader is able to align goals so that both the work and the people grow together. This shared purpose creates momentum while empowering the team to problem solve their issues together and form a healthy social bond.

Bottom-up management: A major difference in this management style from that of the atypical Western leadership style of top-down is that the lean leader believes the people doing the work are the best at figuring out how to do the work. A lean leader does not seek to convince or demand others to do things their way; instead they provide a safe space for inquiry and experimentation to challenge the team to find out what works best.

Guiding by challenge: The lean leader challenges the team by asking questions to evoke problem solving skills and idea sharing within the nurturing environment of the team where processes not people are judged. These challenges are meant to be part of their development and growth in themselves and their work. The work is a moving target and the lean leader ensures the work environment is non-judgmental to allow for innovation toward ultimate efficiency.

The effect of lean leadership is that there is one organization and one vision to continuously improve the processes within the organization while improving themselves. Are you willing to be a lean leader? If yes, you're wanted! Please contact us to learn more of this management style and how the Infinitum healthcare transformation system can improve your organization!

Patients are not widgets and healing is not a production line. So how do the Toyota Production System and Healthcare connect? Read on to find out how!

Lean Management History

The history of the lean concept grew out of the Toyota Motor Company established by Sakichi Toyoda in 1935. In 1950 Eiji Toyoda and Taiichi Ohno studied Western car production because the Japanese output was far less than the US output. Ohno observed two major flaws: large batches that created large inventory, and manufacturing methods that preferred large production over customer preferences. Through observation and small incremental changes the Toyota Production System (TPS) was created to make Toyota a world class auto manufacturer. How did they do it? They utilized the lean principles to manage production, employees, and even suppliers.

Lean Management Connection to All Industries

In 1990 the book The Machine that Changed the World coined the term "lean" production. The authors, Womack, Jones, and Roos, did a 5-million dollar 5-year study and postulated that the manufacturing and technology problems are universal to all of business management. This "transference" of issues meant that by "extension" the same lean principles that were successful for Toyota could help other organizations outside of the non-Japanese enterprises. According to Womack, et al, Western manufacturing companies quickly incorporated five lean principles into their processes:

Identification of customer value - the customer, or patient, determines: what is value and what is waste? For example, a patient may think it a waste of time to be sitting in the waiting room for more than 15 minutes. (There are eight defined wastes: motion, unused talent, inventory, over production, transportation, defects, over processing, and unused creatity.)

Management of "value stream" - there are four value streams (demand management, care delivery, financial viability, new service development & quality improvement) to be managed in balance of each other.

Developing capabilities of flow production - a lean environment is a learning environment where front-line employees are innovators and creators of change.

Use of "pull" mechanisms to support flow of materials at constrained operations - the lean mindset looks to find opportunities to keep the patient moving through the system.

Pursuit of perfection through reducing to zero all forms of "waste" - this is a continuous quality improvement process that is accomplished through the knowledge and utilization of lean methodologies.

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Lean Management for Healthcare

To answer the question: how do the Toyota Production System and healthcare connect? They connect because every industry, including healthcare, is producing something that needs to be managed as efficiently as possible. And that something can be made more efficient by the lean principles and methodologies of lean management that will create a new paradigm around a bottom-up problem solving mindset where waste is removed to create more patient value and practice harmony along with increased demand capacity. What are the people at your healthcare organization producing?

Womack, James P, Daniel T. Jones, and Daniel Roos. The Machine That Changed the World: Based on the Massachusetts Institute of Technology 5-Million Dollar 5-Year Study on the Future of the Automobile. New York: Rawson Associates, 1990. Print.

In an article published in Becker's Hospital Review regarding the best things a healthcare leader did for themselves, their careers and/or their organizations, ten healthcare leaders shared their answer that interestingly aligns with the Infinitum Healthcare Transformation System:

1. Consumer-focused marketing utilizing more research and data driven decisions.

Infinitum will research the entire healthcare organization through surveys, interviews, and assessment tools to create data driven decisions as to the readiness of the work that needs to be done, where there is opportunity for the most benefit for quality improvement, and the best ROI to increase capacity and revenue including possible new service lines.

2. Touching & treating patients as front-line leaders.

Analyzing process and not people, Infinitum consultants work with the front-line staff as they are best positioned to redesign and improve care. Infinitum uses their knowledge of the work area to create collaborative improvements across the organization as a system.

3. Toyota Production System as a management system.

Infinitum methodology includes Toyota's lean thinking as a philosophy that aims to enhance operations through continuous process improvement, standardizing processes, and eliminating waste. This allows an organization to improve patient safety and care, and improve efficiency and capacity. This change in thinking creates a flexible culture of change and utilizes your staff more wisely.

4. Recognizing the need to surround myself with those wiser than myself.

Infinitum Consultants are lean subject matter experts that will assist leaders to promote a consistent day-to-day approach to implementing process improvement across an organization in order to achieve sustainable results and a collaborative culture in the work environment.

5. Always asking "what is best for the patient" across the entire patient experience.

This question is foremost in the Infinitum philosophy of transformation. One of the lean tools that a consultant will teach to employees is an A3. An A3 is an organized-living tool to identify, record, and implement standardized change across the entire patient experience.

6. Intense focus on improving the patient experience.

Analyzing the current state of this experience, identifying issues, finding the root causes, and implementing counter measures to create a future state provides a comprehensive look at the patient experience from their view.

7. Watching my peers grow and being a positive influence for them.

Infinitum University and Infinitum Toolset both provide the knowledge base and experience to influence positive change for the people you lead and the organization you serve.

Infinitum can provide a comparative performance metric database. Within the 8-step Infinitum system there are pre and post assessments that can provide a baseline and comparative data to other organizations.

9. Recognition of quality care.

Infinitum certification is based on the completion of Infinitum University and lean methodology attestation of process adoption. The courses are online for convenience and can be administered at three levels: employee, organization, or both. The employees and the organization will be recognized as quality improvement professionals within a fully efficient certified healthcare system.

10. Assisting other organizations to transition from volume to value-based care.

The Affordable Care Act has changed the way healthcare systems bill for services. This required change has forced practices to look at how they manage and balance care delivery, demand and capacity, financial viability, and new service development along with quality improvement.

Infinitum is the best investment that will assist healthcare professionals and organizations accomplish their goals. Contact us to find out how it can work specifically for your organization!

As much as we all want to think that our work life does not affect our personal life, it does. A study funded by the American Medical Association and published in the Annals of Internal Medicine found that "1 to 2 hours of personal time each night [was spent] doing additional computer and other clerical work." I offer an empathetic and rhetorical, "Why?"

The New Year brings new energy and thoughts of improvements for our lives. How can we be healthier, wiser, and financially better off? In our personal lives, we might be thinking about exercising and eating healthier; working on our relationships; simplifying our lives; and saving more money for investing. In our work lives, we might be thinking about how to reduce the workload; how to minimize stress; how to manage work relationships; and have a better work-life balance. In the same study mentioned above, data showed that "for every hour physicians provided direct clinical face time to patients, nearly 2 additional hours is spent on E.H.R. and desk work within the clinic day." As dedicated professionals you look to give your patients the best possible care, and still complete all the other required tasks. Is there a process manual on how to achieve that and have work-life-balance? Yes, and it is called Infinitum!

Infinitum is a lean transformational healthcare system for practice management that can provide the change you are looking for in your work life and the practice processes. Through lean management assessments and tools, a team of Infinitum consultants will work with you and your staff to bring about the desired changes, increase capacity, and create a team mindset for continuous quality improvement that is sustainable. As healthcare reform transitions to the value based payment model, Infinitum can drive performance measure improvements. Let us show you what Infinitum can do!

Infinitum is the practice management and transformation system from VPQHC. It has been designed from the ground up to allow practices to focus on delivering care in the most effective and efficient ways possible. A comprehensive, yet flexible system allowing "ramp up" activities such as individual improvement projects all the way to full scale practice transformations over multiple years, Infinitum rewires your practice at operational and human levels to enable permanent change.

We've been working on our Infinitum practice management and transformation system to bring it to market in the very near future. Infinitum consists of four elements:

The Infinitum management and transformation methodologies

Infinitum practice coach training and certification

Infinitum certification for practices

The Infinitum practice business process comparative database

Responding to demand, we have accelerated development and launch of Infinitum University, our online learning environment which will administer and provide training courses in the Infinitum methodology. Our first courses will be available in the next couple of months, so if you are interested in discovering more, please email us at leeb@vpqhc.org I'll be happy to talk about the various options for training and development within the Infinitum system. Watch this space for further updates soon!

As 2016 drew to a close, the political environment in the USA was turbulent. In an atmosphere of disinformation as the norm, establishing clear pathways for the continued evolution of the health care reform efforts instigated by MACRA is proving ever more difficult. We simply don't know what the effects of this sharp political direction change may be, and that only fuels the uncertainty felt in the health care system as a whole.

What we do know however, is that the basic premise of the health care reform movement in the USA is unchanged. The system as it is currently configured is inherently flawed, the net result of those flaws being the double digit increases in health insurance premiums we have been seeing for the last few years. This situation is as unsustainable now as it was in 2016, and so the rationale behind MACRA remains the same too. The House and Senate realized this and backed MACRA in a bipartisan manner. Since then some of the provisions have been enacted and now the implications are beginning to be felt throughout the system. This is the equivalent of the supertanker changing course, but instead of physical momentum taking the ship 10 miles before being able to execute a turn, we have political momentum driving the system forward, but with the course corrections inherent in MACRA slowly turning the system to a new direction. This takes progressive time, unless a tipping point is achieved whereby the desire for change overcomes the threshold level of resistance forces against it. I can feel that tipping point rapidly approaching.

What does this look like at each level in the health care system? Clearly there are some themes that are relatively constant. Costs are increasing, demand is increasing, supply (of qualified providers and associated resources) is decreasing and wages are stagnant. Whichever level you work at, the net result of these factors is increasing pressure to understand your costs, how they arise and how you can reduce them. In a system that has shown little appetite for exposing those costs, this pressure begins to stress the system as a whole. That stress rails against the system constraints, such as politico-economic forces, resulting in decreasing performance, an exodus of trained providers exacerbating the already diminished pool and more patients postponing or neglecting to engage with the system in anything other than catastrophic ways (typically by presenting at the ED).

Systems thinking teaches us to look at the root causes of system conditions and address them to achieve sustained improvements in performance. Identifying and working with organizations to improve these conditions is a core specialty at VPQHC. Email me at leeb@vpqhc.org if you would like to find out how we can assist you to get an understanding of your costs, a plan to improve them and sustained assistance in implementing those plans.

In my work with medical practices, hospitals and other organizations there is one almost universal issue that arises, seemingly to stop any progress dead.

"How am I supposed to find the time to do all this? My practice is already swamped with work, we're not getting home on time, staff are frazzled and now you're telling me I need to develop a Vision and Aims for it? I don't have the time right now. Sorry."

My reaction is always the same. From a systems thinking standpoint, the system is perfectly engineered to produce the results it is producing at any given time. If the results show stress in the system, there are clearly difficulties within the system that lead to this stress. Without addressing the root causes of this stress, the system will continue to exhibit these characteristics and life as we know it will not change. It is a self limiting system, and without breaking from the cycle of acceptance of current conditions, the system will not change.

Breaking from the cycle of acceptance requires two things:

An understanding of the situation

A commitment to perform an action to solve something. Anything that will release capacity that is currently being consumed in wasted activities.

Understanding the situation requires the ability to see the system itself. This is where the services of an experienced practice coach can be invaluable, as they are skilled in helping owners change perceptions and see systems differently. Once the situation is fully grasped, making a commitment to release currently consumed capacity can occur. The specific business process to work on to release the capacity is of course completely dependent on current circumstances and should be evaluated with the practice coach.

It cannot be stressed enough how important this first step is to a successful transformation. Proving that capacity can be released by reconfiguration of business processes is the key to unlocking more activities and eventually, full system redesign and transformation. VPQHC is experienced in this work and can help take your practice to performance levels which will enable it to thrive in the new value based payments structures currently being introduced by CMS. If you would like to find out more, contact me at leeb@vpqhc.org for an introductory discussion.

Part of our work at VPQHC is with the Northern New England Practice Transformation Network (NNE-PTN) working with practices to help them transition their operations to be more successful in the upcoming value based payment systems such as Advanced Alternative Payment Models (AAPM's) and the new Merit Based Incentive Payment system (MIPS). We use a transformation methodology from CMS called the Transforming Clinical Practices Initiative (TCPI) which examines a practice within 27 distinct domains, evaluating the maturity level of each domain and producing a structured action plan to take those domains to their next stages of maturity. It's a complex process, and takes significant time, which is why the typical TCPI engagement lasts four years.

The Medicare Access and CHIP Re authorization Act of 2015 (MACRA) mandated CMS with producing the MIPS system to replace the PQRS, Value Based Modifier, Meaningful Use and Resource Utilization Index measures, and produce one integrated system to be a "catch all" for practices that are not joining an advanced alternative payment model such as an Accountable Care Organization (ACO). (Practices joining ACO's have their own criteria and system to ensure they move to value based payments.)

The time line for these changes has caught a lot of practices by surprise. The first reporting year starts Jan 1 2017 (in about 6 weeks) and many practices either do not know of these changes, or are doing very little to change their operations to work within the new system. MIPS has provisions to impose positive and negative modifiers on medicare payments, beginning with +/- 4% in 2019 (based on 2017 results) and up to +/- 9% in 2022 (based on 2020 results). If your practice has significant medicare billings, these figures will start to impact your financial performance starting 2019.

TCPI is designed to help you navigate MIPS, submit data to CMS appropriately and design your operations to more effectively produce value, which is reflected in the MIPS scores. For any practices that are not currently in an advanced alternative payment model, a CMMI demonstration project (such as the Blueprint for Health in VT) or other CMS funded program, TCPI offers 3 years of free technical assistance to help you configure your practice to succeed in this new environment. In VT we currently have 22 practice slots available for the TCPI program. If you would like to discuss options, please don't hesitate to contact me at leeb@vpqhc.org

At VPQHC we cover the whole spectrum of healthcare in Vermont, and increasingly the whole care continuum as the United States begins to change thinking in this area to embracing the social and behavioral determinants of health. As the only neutral healthcare quality organization mandated by statute in the state of Vermont, we take our role in guiding the development of the statewide healthcare quality system very seriously.

Primary Care and Specialty Practices have been historically under served with high quality, independent assistance in their operations, strategy and growth pathways as they struggle to adapt to the rapidly changing world of value based compensation from the traditional fee for service world. Recognizing this, we took a long hard look at the needs of this sector, matched it with our broad and deep experience and expertise bases and developed a practice transformation center of excellence.

"What's a practice transformation center of excellence?" Well, we have been the Vermont partner in the Northern New England Practice Transformation Network for over a year now, assisting practices across the state (and in NH) with their efforts to transform their structures and operations to better live in the changing reimbursement environment of MACRA and MIPS. We have been instrumental in refining and extending the Transforming Clinical Practices Initiative (TCPI) methodology into a system that truly guides the practice to a higher performing state. In addition to this, we have taken our own experience bases and extended our practice transformation system far beyond that in TCPI to a truly holistic system capable of taking any practice from struggle to supreme performance. We call it the Infinitum Method because the scope of improvement is limitless with the right guidance and coaching.

Over the coming months, you'll begin to see more about this in our materials, communications and events. As we launch educational and service offerings, we will be in touch to get your feedback and discuss opportunities for us to work together to truly transform your practice. If this is something you would like to find out more about, please call us on (802) 229 2152 or email me at leeb@vpqhc.org

Creating a culture of quality through education, measurement, and collaboration.